Subjective notes
What did the patient say?
Provide as much detail as you can and describe the patients own words about themselves in terms of their function, disability, symptoms and history. Also include information from any family or caregivers and, if specific phrasing is used, enclose this in quotation marks. This will allow you or a future therapist to document the patients perception of their condition precisely and how it relates to their progress in rehabilitation, functional performance or quality of life.
Dont:
- Pass judgement on a patient e.g. "Patient is over-reacting again".
- Document irrelevant information e.g. patient complaining about previous therapist.
essentially...
- What did the patient say?
- What did the caregiver say?
- Any documentation from other health professionals?
- What was the VAS scale?
Using notes:
Simply type a note and press "Enter" key. You can edit existing notes or delete a note. To delete all your notes, use "Clear". However, as this will remove all notes on this page it is advised to copy and paste them into a document and store them elsewhere before clearing them here.
